CMS HCRIS Data dictionary - onetomapanalytics/Meta_Data GitHub Wiki

CMS HCRIS - Hospital Cost Reports - Data dictionary

Column Code TABLES SUBSYSTEM Null/Not Null Title Description Valid Entries
ADR_VNDR_CD RPT ALL NULL Automated Desk Review Vendor Code Vendor for Fiscal Intermediary. 2 or A03 - E & Y 3 or A01 - KPMG 4 or A05 - HFS
ALPHNMRC_ITM_TXT ALPHA ALL NOT NULL Alphanumeric Item Text Provider reported alpha data. Per Specification Table
CLMN_NUM ALPHA,NMRC HOSP10 NOT NULL Column Number Valid Column Number defined as follows: xxxyy where xxx = Column Number and yy = Sub-Column Number Example: Column 1 = 00100, Column 1.01 = 00101
CLMN_NUM ALPHA,NMRC ALL BUT HOSP10 NOT NULL Column Number Valid Column Number defined as follows: xxyy where xx = Column Number and yy = Sub-Column Number Example: Column 1 = 0100, Column 1.01 = 0101
FI_CREAT_DT RPT ALL NULL Fiscal Intermediary Create Date Date the FI created the HCRIS file. MM/DD/YYYY
FI_NUM RPT ALL NULL Fiscal Intermediary Number Fiscal Intermediary Number in effect at the time of cost report filing. Assigned FI Number
FI_RCPT_DT RPT ALL NULL Fiscal Intermediary Receipt Date Date cost report was received by Fiscal Intermediary. MM/DD/YYYY
FY_BGN_DT RPT ALL NULL Fiscal Year Begin Date Cost Report Fiscal Year beginning date. MM/DD/YYYY
FY_END_DT RPT ALL NULL Fiscal Year End Date Cost Report Fiscal Year ending date. MM/DD/YYYY
INITL_RPT_SW RPT ALL NULL Initial Report Switch Y or N, Y = the first cost report filed for this provider. (Not actively used.) Y, N or blank
ITM_VAL_NUM NMRC ALL NOT NULL Item Value Number Provider reported numeric data. See ECR Specifications Table
LAST_RPT_SW RPT ALL NULL Last Report Switch Y or N, Y = the final cost report filed for this provider. (Not actively used.) Y, N or blank
LINE_NUM ALPHA,NMRC ALL NOT NULL Line Number Valid Line Number defined as follows: xxxyy where xxx = Line Number and yy = Sub-Line Number Example: Line 1 = 00100, Line 1.01 = 00101
NPR_DT RPT ALL NULL Notice of Program Reimbursement Date Date Provider received NPR. MM/DD/YYYY
NPI RPT ALL NULL National Provider Identifier Unique health identifier for health care providers. Established under HIPAA. Assigned NPI Number
PROC_DT RPT ALL NULL Process Date The date the cost report was processed into HCRIS. MM/DD/YYYY
PRVDR_CTRL_TYPE_CD RPT ALL NULL Provider Control Type Code Type of ownership from Table 3A of Specifications. See Table
PRVDR_NUM RPT ALL NOT NULL Provider Number Valid Provider Number defined as follows: xxyyyy where xx = State Code and yyyy = Assigned Provider Range
RPT_REC_NUM RPT,ALPHA,NMRC,ROLLUP ALL NOT NULL Report Record Number HCRIS assigned cost report specific number.
RPT_STUS_CD RPT ALL NOT NULL Report Status Code Type of cost report. 1 = As Submitted 2 = Settled w/o Audit 3 = Settled with Audit 4 = Reopened 5 = Amended
SPEC_IND RPT ALL NULL Special Indicator HCRIS code used for special purposes.
TRNSMTL_NUM RPT ALL NULL The current transmittal or version number in effect for each sub-system. Transmittal Number or transmittal version used to create the cost report
UTIL_CD RPT ALL NULL Utilization Code Level of Medicare utilization of filed cost report. L - Low Medicare Util N - No Medicare Util F - Full Medicare Util Blank - Full Medicare Util
LABEL ROLLUP HOSP, HHA, SNF, HOSP10 NOT NULL Rollup label Descriptive text label
ITEM ROLLUP HOSP, HHA, SNF, HOSP10 NOT NULL Rollup value Rollup number.
WKSHT_CD ALPHA,NMRC ALL NOT NULL Worksheet Identifier Valid worksheets are defined for each subsystem in other documentation.

Data file:

WORKSHEET S
DESCRIPTION LINE(S) COLUMN(S) FIELD FIELD SIZE USAGE
Part O:
Cost Report Status Code (1=as submitted) (2=settled)
(3=settled with audit) (4=reopened) (5=amended) 1 1 1 X
Date the "As Submitted" Cost Report was received from
the provider (MM/DD/YY) 1 2 8 X
Enter I for Initial, F for Final, N for neither 1 3 1 X
Nu mber of times report has been Reopened 1 4 2 X
Fiscal Intermediary Number 2 2 5 X
Notice of Program Reimbursement Date (MM/DD/YY) 2 4 8 X
Part II:
Balances due Provider or (Program) in Total
Title V 100 1 11 -9
Title XVIII, Part A 100 2 11 -9
Title XVIII, Part B 100 3 11 -9
Title XIX 100 4 11 -9
Balances due Provider or (Program) by Component:
Title XVIII, Part A 1-3, 5, 7 2 11 -9
Title XVIII, Part B 1-3, 5, 7, 8 3 11 -9
Title XIX 1--8 4 11 -9
Balances due Provider or (Program) for ICF:
Title XIX 6,01 4 11 -9
Balances due Provider or (Program) for RHC/FQHC:
Title XVIII, Part B 9 3 11 -9
Title XIX 9 4 11 -9
WORKSHEET S-2
DESCRIPTION LINE(S) COLUMN(S) FIELD FIELD SIZE USAGE
Hospital and Health Care Complex Address:
Street 1 1 36 X
P.O. Box 1 2 9 X
City 1,01 1 36 X
State 1,01 2 2 X
Zip Code (xxxxx-xxxx or xxxxx left justified) 1,01 3 10 X
County 1,01 4 36 X
For the Hospital:
Name 2 1 36 X
Provider Number (xxxxxx) 2 2 6 X
National Provider Identifier 2 2A 10 X
Certification Date (MM/DD/YY) 2 3 8 X
Title XVIII Payment System 2 5 1 X
Title XIX Payment System 2 6 1 X
T4:
1. Worksheet S, Part II: Line 6.01, col 4 for the ICF/MR T14:
2. Wksht S, Part II, Line 9, Columns 3 and 4 Line 1, Columns 1, 3, & 4, and Line 2, Columns 2 &4 added.
For each Subprovider, each Hospital-Based Hospice,
the Separately Certified ASC, each Hospital-Based Clinic,
each Outpatient Rehabilitation Provider, and each Renal
Dialysis:
Provider Number (xxxxxx) 3, 11, 12, 14-16 2 6 X
National Provider Identifier 3, 11, 12, 14-16 2A 10 X
Certification Date (MM/DD/YY) 3, 11, 12, 14-16 3 8 X
Title XVIII Payment System 3, 11, 12, 14, 15 5 1 X
Title XIX Payment System 3, 11, 12, 14, 15 6 1 X
For the Swing-Bed SNF, the Hospital-Based SNF, and
each Hospital-Based HHA:
Provider Number (xxxxxx) 4, 6, 9 2 6 X
National Provider Identifier 4, 6, 9 2A 10 X
Certification Date (MM/DD/YY) 4, 6, 9 3 8 X
Title XVIII Payment System 4, 6, 9 5 1 X
Title XIX Payment System 4, 6, 9 6 1 X
For the Swing-Bed NF and the Hospital-Based NF:
Provider Number (xxxxxx) 5 & 7 2 6 X
National Provider Identifier 5 & 7 2A 10 X
Certification Date (MM/DD/YY) 5 & 7 3 8 X
Title XIX Payment System 5 & 7 6 1 X
For the ICF/MR:
Provider Number (xxxxxx) 7,01 2 6 X
National Provider Identifier 7,01 2A 10 X
Certification Date (MM/DD/YY) 7,01 3 8 X
Title V Payment System 7,01 4 1 X
Title XIX Payment System 7,01 6 1 X
T7:
Transmittal 7 closed Line 12, Columns 5 and 6. HCRIS
still wants to collect Line 12, Columns 5 and 6 for older cost reports
if they are contained in the ECR file.
Type of Control (Refer to HCFA Pub.15-I, S3604) 18 1 2 X
Type of Hospital and Subprovider (Refer to HCFA Pub.15-I,S3604) 19, 20 1 1 X
Indicate if this Hospital is either (1) Urban or (2) Rural 21 1 1 X
If your hospital is geographically classified or located in a rural
area, is your bed size less than or equal to 100 beds? (Y/N) 21 2 1 X
Does this facility qualify and is currently receiving paymnets
for disproportionate share in accordance with 42 CFR 412.106? (Y/N) 21,01 1 1 X
Is this facility subject to the provisions of 42 CFR 412.106(c)(2)
(Pickle amendment hospitals?) (Y/N) 21,01 2 1 X
Has your facility receive geographic reclassification? (Y/N) 21,02 1 1 X
If Line 21.02, Col 1 is 'yes', report the effective date 21,02 2 8 X
Enter in column 1 your geographic location either (1) urban
(2) rural. 21,03 1 1 9
If you answered urban in column 1 indicate if you received
either: a wage or standard geographic reclassification to a
rural location, enter in column 2 "Y" for yes and "N" for no. 21,03 2 1 X
If column 2 is yes, enter in column 3 the effective date
(mm/dd/yy) 21,03 3 8 X
Does your facility contain 100 or fewer beds in accordance with
42 CFR 412.105? (Y/N) 21,03 4 1 X
Provider's actual MSA or CBSA 21,03 5 5 X
For standard geographic reclassification (not wage), what is the
status at the beginning of the cost reporting period. Enter (1)
for urban (2) for rural. 21,04 1 1 9
For standard geographic reclassification (not wage), what is the
status at the end of the cost reporting period. Enter (1)
for urban (2) for rural. 21,05 1 1 9
Does the hospital qualify for the 3 yr transition of hold harmless
payments for small rural hospitals under the PPS for hosptial
outpatient department services under DRA, section 5105 or
the extension of this provision uner MIPPA, section 147 effective
for services rendered from 1/1/09 thru 12/31/09? (Y/N) 21,06 1 1 X
Does this hospital qualify as a SCH with 100 or fewer beds under 21,07 1 1 X
MIPPA 147? (Y/N)
T12: Worksheet S-2, Line 21, Col 2 added.
T12: Worksheet S-2, Lines 21.03, Columns 1 - 4 added and Lines 21.04 and 21.05, Column 1 added.
T16: Worksheet S-2, Line 21.06, Column 1 added.
T17: Worksheet S-2, Line 21.03, Column 5 added.
T19, Flash 2: Worksheet S-2, Line 21.06 description expanded to include MIPPA
T20: Worksheet S-2, Line 21.07 added.
T21: Worksheet S-2, Line 21.01, Column 2 added.
Is this a SCH or EACH that qualifies for the Outpatient Hold
Harmless provision in ACA Section 3121?
Enter in colun 2 "Y" for yes or "N" for no. 21,07 2 1 X
Which method is used to determine Medicaid days?
Enter 1 if it is based on date of admission,
2 if it is based on census days, or 3 if it is based on
date of discharge 21,08 1 1 9
Is this method different than the method used in the preceding cost reporting period? (Y/N)
21,08 2 2 X
T21: Line 21.08, Columns 1 and 2 added.
T22: Line 21.07, Column 2 added.
Is this Hospital classified as a Referral Center? (Y/N) 22 1 1 X
Does this Facility operate a Transplant Center? (Y/N) 23 1 1 X
Certification Dates in MM/DD/YY format:
Medicare Certified Kidney Transplant Center 23,01 2 8 X
Medicare Certified Heart Transplant Center 23,02 2 8 X
Medicare Certified Liver Transplant Center 23,03 2 8 X
Medicare Certified Lung Transplant Center 23,04 2 8 X
If Medicare Pancreas Transplants are performed,
enter the more recent date of July 1, 1999 or the
certification dates for the kidney transplants
(MM/DD/YY) 23,05 2 8 X
Medicare Certified Intestinal Transplant Center 23,06 2 8 X
Medicare Certified Islet Transplant Center 23,07 2 8 X
(MM/DD/YY) for all these termination dates
Medicare Certified Kidney Transplant Center Termination Dt 23,01 3 8 X
Medicare Certified Heart Transplant Center Term Date 23,02 3 8 X
Medicare Certified Liver Transplant Center Term Date 23,03 3 8 X
Medicare Certified Lung Transplant Center Term Date 23,04 3 8 X
Medicare Certified Pancreas Transplant Center Term Dt 23,05 3 8 X
Medicare Certified Intestinal Transplant Center Term Date 23,06 3 8 X
Medicare Certified islet Transplant Center Term Date 23,07 3 8 X
If an Organ Procurement Organization (OPO), what is the
OPO Number? 24 2 6 X
OPO Term Date (MM/DD/YY) 24 3 8 X
If this is a Medicare transplant center, Enter the CCN 24,01 2 6 X
Enter the certification date or recertification date 24,01 3 8 X
(after 12/26/07)
T17: Line 23.07, Column 2 added.
T18: Worksheet S-2, Lines 23.01 - 24, Column 3 added.
T19: Worksheet S-2, Line 24.01, Columns 2 and 3 added.
Is this a teaching hospital or affiliated with a teaching hospital? (Y/N) 25 1 1 X
Is this teaching program in accordance with
HCFA Pub 15-I, Chap 4? (Y/N) 25,01 1 1 X
If line 25.01 is yes, was Medicare participation and approved teaching
program status in effect during the first month of the cost reporting period? If
"Y", complete Wkst. E-3, Part IV. If "N", complete Wkst. D-2, Part II. 25.02 1 1 X
As a teaching hospital, did you elect cost reimbursement for physicians'
services as defined in CMS Pub. 15-I, section 2148? If "Y", complete
Worksheet D-9. 25.03 1 1 X
Are you claiming costs on line 70 of Worksheet A? If "Y", complete
Worksheet D-2. 25.04 1 1 X
Has your facility's direct GME FTE cap been reduced under
42 CFR Secs. 413.79 (c)(3) or 413.105(f)(l)(iv)(B)? Enter "Y"
for yes and "N" for no. 25,05 1 1 X
Has your facility's direct IME FTE cap been reduced under
42 CFR Secs. 413.79 (c)(3) or 413.105(f)(l)(iv)(B)?
Enter "Y" for yes and "N" for no. 25,05 2 1 X
Has your facility received additional GME FTE resident cap
slots under 42 CFR Secs 413.79 ( c)(4)
or 412.105(f)(l)(iv)( C)? Enter "Y" for yes and "N" for no. 25,06 1 1 X
Has your facility received additional IME FTE resident cap
slots under 42 CFR Secs 413.79 ( c)(4)
or 412.105(f)(l)(iv)( C)? Enter "Y" for yes and "N" for no. 25,06 2 1 X
Has your facility’s trained residents in non profit setting during the
cost reporting period? Enter "Y" for yes or
"N" for no in column 1 25,07 1 1 X
If line 25.07 is yes, enter in column 1 the weighted number of
non-primary care FTE residents attributable to rotations occuring
in all non-provider settings. 25,08 1 9 9(6).99
If line 25.07 is yes, enter in column 1 the unweighted number of
primary care FTE residents attributable to rotations occuring in all
non-provider settings:
Program name 25.09-25.50 1 12 X
Program code 25.09-25.50 2 9 X
Number of unweighted FTE by specialty for each primary care specialty
program in which residents are trained 25.09-25.50 3 9 9(6).99
T15:
Worksheet S-2, lines 25.05 and 25.06, colums 1 and 2 added.
T23:
Worksheet S-2, Lines 25.07 thru 25.50
If this is a Sole Community Hospital (SCH), enter the # of periods. 26 1 1 9
If this is a SCH, enter the applicable SCH dates:
Beginning 26,01 1 8 X
Ending 26,01 2 8 X
Beginning 26,02 1 8 X
Ending 26,02 2 8 X
If this a sole community hospital (SCH) for any part of the
cost reporting period, enter the number of periods within this
cost reporting period that SCH status was in effect and SCH was
either physically located or classified in a rural area. 26,03 1 1 9
Beginning date SCH status applies in this period (mm/dd/yy) 26,04 1 8 X
Ending date SCH status applies in this period (mm/dd/yy) 26,04 2 8 X
Beginning date SCH status applies in this period (mm/dd/yy) 26,04 3 8 X
Ending date SCH status applies in this period (mm/dd/yy) 26,04 4 8 X
Does this Hospital have an agreement under either section 1883 or
section 1913 for "swing beds"? (Y/N) 27 1 1 X
If 27 is yes, enter the agreement date (MM/DD/YY) 27 2 8 X
T12:
Worksheet S-2, Line 26.03, Column 1 and Line 26.04, Columns 1 - 4 added.
06/06/2004: Added Line 26.02 to specs. Before there was just a note saying to subscript Line 26.01 if more than 1 period
of SCH status is identified.
T15:
Worksheet S-2, line 26.02, columns 1 and 2 usage changed from 8 to 10.
If this facility contains a hospital based SNF, are all
patients under managed care or there were no Medicare
utilization enter 'Y', if 'N' complete lines 28.01 and 28.02
Applicable for reporting periods beginning on or after 7/1/98 28 1 1 X
If hospital based SNF, enter appropriate transition period 28,01 1 3 9
Wage index adjustment factor for applicable period 28,01 2 11 9(7).9(4)
Wage index adjustment factor for applicable period 28,01 3 11 9(7).9(4)
Hospital Based SNF Facility Specific Rate 28,02 1 11 9(9).9(2)
Is SNF urban (1) or rural (2)? 28,02 2 1 X
SNF MSA Code or 2 character SSA state code if a Rural
based facility 28,02 3 4 X
Hospital Based SNF CBSA code or State Code 28,02 4 5 X
A notice published in the Federal Register Vol. 68 No. 149 which
provided for an increase in the RUG payments for services
beginning 10/01/2003. This increase is expected to be used for
direct patient care and related expenses.
Enter the percentage of total expenses for each of the following
categories to total SNF revenue from inpatient care service
Staffing 28,03 1 4 9,99
Recruitment 28,04 1 4 9,99
Retention of employees 28,05 1 4 9,99
Training 28,06 1 4 9,99
Is the increased spending associated with direct patient care
and related spending reflects each of the categories? (Y/N)
Staffing 28,03 2 1 X
Recruitment 28,04 2 1 X
Retention of employees 28,05 2 1 X
Training 28,06 2 1 X
Other (Specify) 28-07-28.20 0 36 X
Enter the percentage of total expenses for other expenses
to total SNF revenue from inpatient care service 28-07-28.20 1 4 9,99
Is the increased spending associated with direct patient care
and related spending reflects Other?(Y/N) 28-07-28.20 2 1 X
T11:
Lines 28.03 through 28.20 added.
T15:
Lines 28.02, column 4 added.
Is this a Rural Hospital with a certified SNF which has fewer
than 50 beds in the aggregate for both components,
using the swing bed optional method of reimbursement? (Y/N) 29 1 1 X
Does this Hospital qualify as a RPCH/CAH? (Y/N) 30 1 1 X
Is this cost reporting period initial 12 month period for
which the facility operated as RPCH/CAH? (Y/N)
30,01 1 1 X
If this Facility qualifies as a RPCH/CAH, has it elected the
all inclusive method of payment for outpatient service?
For reporting periods beginning on or after October 1, 2000
CAHs can elect the all inclusive payment for outpatient.
(Y/N) 30,02 1 1 X
If this Facility qualifies as a CAH, is it eligible for cost
reimbursement for ambulance services? 30,03 1 1 X
Eligiblility Determination Date (MM/DD/YY) 30,03 2 8 X
If facility qualifies as a CAH is it eligible for cost
reimbursement for I&R? (Y/N) 30,04 1 1 X
Is this a rural hospital qualifying for an exception to the certified registered
nurse anesthetist the CRNA fee schedule? (Y/N) 31 1 1 X
Does the RPCH have a Subprovider that qualifies for an
exemption to the CRNA fee schedule? (Y/N) 31,01 1 1 X
Is this Hospital an All-Inclusive Rate Provider? (Y/N) 32 1 1 X
If yes, enter the method used: (A, B, or E only) 32 2 1 X
Is this a New Hospital under 42 CFR 412.300 PPS Capital? (Y/N) 33 1 1 X
If yes (for periods beginning on or after 10/1/2002)
do you elect to be reimbursed at 100% (Y/N) 33 2 1 X
Is this a New Hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)?(Y/N) 34 1 1 X
Have you established a new subprovider excluded unit under 42 CFR
413.40(f)(1)(i)?(Y/N) 35 1 1 X
T10: Line 30.04, Column 1 added.
Line 33, Column 2 added.
Line 2, Column 5 = "P":
Does this Hospital elect a fully prospective payment
method for capital costs? (Y/N) 36 2 1 X
Does the facility qualify and receive payment for disproportionate
share in accordance with 42 CFR 412.320? (Y/N/P) 36,01 2 1 X
Does this Hospital elect a hold harmless payment
method for capital costs? (Y/N) 37 2 1 X
If 37 is yes, is this Hospital filing on the basis of 100% of the
federal rate? (Y/N) 37,01 2 1 X
Does this Hospital have Title XIX inpatient hospital services? (Y/N) 38 1 1 X
Are Title XIX NF patients occupying Title XVIII SNF beds
(dual certification)? (Y/N) 38,03 1 1 X
Does this facility operate an ICF/MR facility for
purposes of Title XIX? (Y/N) 38,04 1 1 X
Are there any related organIzation or home office costs as defined
in HCFA Pub. 15-I, Chapter 10? (Y/N) 40 1 1 X
If Line 40, Col 1 is 'yes' and there are home office costs and you are part
of a chain, report the home office provider number 40 2 6 X
Home Office Name 40,01 1 36 X
FI/Contractor's Name 40,01 2 36 X
FI/Contractor's Number 40,01 3 5 X
Home Office Street 40,02 1 36 X
Home Office PO Box 40,02 2 9 X
City 40,03 1 36 X
State 40,03 2 2 X
Zip Code 40,03 3 10 X
Are provider based physicians' costs included in Worksheet A? (Y/N) 41 1 1 X
Are physical therapy services provided by outside suppliers? (Y/N) 42 1 1 X
Are occupational therapy services provided by outside
suppliers? (Y/N) 42,01 1 1 X
Are speech therapy services provided by outside
suppliers? (Y/N) 42,02 1 1 X
Are respiratory therapy services provided by outside suppliers? (Y/N) 43 1 1 X
If this Hospital is claiming cost for the renal services on Worksheet A,
are they inpatient services only? (Y/N) 44 1 1 X
T7: Line 40, Column 2 added.
T16: Worksheet S-2, Lines 40.01 through 40.03 added.
T17: Line 40.01, Column 2 and 40.01, Column 3 added.
Has this Hospital changed its cost allocation method from the
previously filed cost report? (Y/N) 45 1 1 X
If 45 is yes, enter the approval date 45 2 8 X
Was there a change in the statistical basis? (Y/N) 45,01 1 1 X
Was there a change in the order of allocation? (Y/N) 45,02 1 1 X
Was there a change to the simplified cost finding
method? (Y/N) 45,03 1 1 X
If this hospital participates in the NHCMQ Demonstration
project (must have a hospital based SNF) during this cost 46 1 1 9
reporting period, enter the phase number.
If this facility contains a provider that qualifies for an exemption
from the application of the lower of costs or charges, enter
'Y' for each component and type of service that qualifies
for the exemption, enter 'N' if not exempt (See 42 CFR 413.13).
Hospital 47 1--5 1 X
Subprovider 48 1--5 1 X
SNF 49 1 & 2 1 X
HHA 50 1 & 2 1 X
Outpatient Rehabilitation Provider 51 2 1 X
Does this hospital claim expenditures for extraordinary
circumstances in accordance with 42 CFR 412.348(e)? (Y/N) 52 1 1 X
If you are a fully prospective or hold harmless provider
are you eligible for the special exceptions payment 52,01 1 1 X
pursuant to 42 CFR? (Y/N)
T10: Line 52.01, Column 1 added.
If this is a medicare dependent hospital (MDH), enter
the number of periods MDH status in effect. 53 1 1 9
MDH beginning date 53.01-53.03 1 8 X
MDH ending date 53.01-53.03 2 8 X
Malpractice Premiums 54 1 11 9
Malpractice Paid Losses 54 2 11 9
Malpractice Self Insurance 54 3 11 9
Are Malpractice premiums and paid losses reported in
other than Administrative and General cost center?
(Y/N) 54,01 1 1 X
Does your facility qualify for additional prospective
payment in accordance with 42 CFR 412.107? (Y/N) 55 1 1 X
Are you claiming ambulance costs? (Y/N) 56 1 1 X
If yes, enter the payment limit 56 2 11 9(9).9(2)
If Line 56, Column 1 is 'Y', is this your first
year of operation for rendering ambulance
services? (Y/N) 56 3 1 X
Fees 56 4 11 9
Enter subsequent ambulance payment limit 56.01-56.03 2 11 9(9).9(2)
Fees 56.01-56.03 4 11 9
Effective Date of Ambulance Limit (MM/DD/YY) 56-56.03 0 8 X
Are you claiming nursing and allied healt costs? (Y/N) 57 1 1 X
Note: Subscript Line 53.01, Columns 1 and 2 if more than 1 period is identified for this cost reporting period and enter multiple dates. HCRIS only wants this line reported up to 3 times (53.01-53.03),
Are you an Inpatient Rehab Facility (IRF) or do you
contain an IRF subprovider? (Y/N) 58 1 1 X
Have you made election for 100% Federal PPS
reimbursement? (Y/N) 58 2 1 X
If Line 58, Column 1 is Yes, does the facility have
a teaching program in the most recent cost reporting
period ending on or before November 15, 2004? (Y/N) 58,01 1 1 X
Is the facility training residents in a new teaching program
in accordance with FR Vol. 70, No. 156? (Y/N) 58,01 2 1 X
If Line 58.01, Column 2 is 'Y', enter 1, 2, or 3 respectively.
If the current cost reporting period covers the beginning
of the 4th, enter '4' or if the subsequent academic years
of the new teaching program in existence, enter '5' 58,01 3 1 9
Are you a LTCH or do you contain a LTCH subprovider?
(Y/N) 59 1 1 X
Have you made election for 100% Federal PPS
reimbursement? (Y/N) 59 2 1 X
If column 2 is Y, enter 1, 2 or 3 respectively in column 3.
(see instructions). If the current cost reporting period covers the beginning of the fourth enter 4 in column 3,
or if the subsequent academic years of the new teaching program in existence, enter 5 . (see instructions)
T10: Line 58, Column 1 - description changed.
Line 58, Column 2 added.
Line 59, Columns 1 and 2 added.
T16: Worksheet S-2, Line 58.01, Columns 1 through 3 added.
09/27/2006: Line 58.01, Column 4 removed.
Are you an Inpatient Psychiatric Facility (IPF)
or do you contain an IPF subprovider? (Y/N) 60 1 1 X
If Line 60, Column 1 is Yes, is this a new facility
in accordance with CR 3752? (Y/N) 60 2 1 X
If line 60, column 1 is Y, and the facility is an IPF subprovider,
were residents training in this facility in its most recent 60,01 1 1 X
cost reportint period filed before November 15, 2004?
Does the facility have a new teaching program
in accordance with 42 CFR? (Y/N) 60,01 2 1 X
If Line 60.01, Column is Y, enter 1, 2 or 3.
If the current cost reporting period covers the beginning
of the fourth enter 4 in column 3,
or if the subsequent academic years of the new teaching
program in existence, enter 5. 60,01 3 1 9
Is this facility a part of a Mulicampus that has one
or more campuses in different CBSAs (Y/N) 61 1 1 X
If Line 61 is yes, enter the name 62 0 36 X
If Line 61 is yes, enter the County 62 1 36 X
If Line 61 is yes, enter the State 62 2 2 x
If Line 61 is yes, enter the Zip Code 62 3 10 x
If Line 61 is yes, enter CBSA 62 4 5 x
If Line 61 is yes, enter FTE count/campus 62 5 9 9(6).99
Was the cost report filed using the PS&R (either in its entirety
or for total charges and days only)? Enter "Y" for yes and "N" for
no in column 1. 63 1 1 X
If column 1 is "Y", enter the "paid through" date
for the PS&R in column 2 (MM/DD/YY) 63 2 8 X
Did this faclity incur and report costs for implantable devices charged to
patient? Enter in column 1 "Y" for yes or "N" for no. 64 1 1 X
T14: Worksheet S-2, Lines 60 and 60.01 added.
T18: Worksheet S-2, Lines 61 and 62 added. (Line 61, Column 1 was added to the front end before vendors were approved for T18
and T19. HCRIS soon be getting a business owner so it was decided to add this field so cost report extracts would not reject.)
T19: Worksheet S-2, Line 60.01, Column 1 description changed.
T19: Worksheet S-2, Line 63, Columns 1 and 2 added.
T23: Worksheet S-2, Line 64 added.
Note: Line 62 can be subscripted. HCRIS allows Lines 62.01 through 62.09.
WORKSHEET S-3 - PART I
DESCRIPTION LINE(S) COLUMN(S) FIELD SIZE USAGE
Part I: For Hospital Adults & Pediatrics (Excluding Swing Beds, et al),
the HMO, Hospital Adults and Pediatrics for Swing Bed SNF,
Hospital Adults and Pediatrics for Swing Bed NF, Total
Adults & Pediatrics (excluding Observation Beds), each Special
Care Unit, the Nursery, in Total for the Hospital, RPCH Visits,
each Subprovider, each Hospital Based SNF, each Hospital Based
NF, each hospital based ICF/MR, each Hospital Based OLTC,
each Hospital Based HHA, each ASC (Distinct Part), each Hospice
(Distinct Part), each Hospital Based Outpatient Rehabilitation Provider,
each FQHC/RHC, and in Total for entire facility:
Number of Beds by Department and in Total 1, 5-10,12, 14-16, 16.01, 17, 21, 25 1 11 9
Bed Days Available 1, 5-12, 14-16, 16.01, 17, 21 2 11 9
Hours CAH patients spend in 1, 6-10 2,01 11 9(9).9(2)
Title V Inpatient Days/Outpatient Visits 1, 3-16, 16.01, 18, 23, 24 3 11 9
Title XVIII Inp Days/Outpatient Visits 1, 3, 5-10, 12-15, 18, 21, 23, 24 4 11 9
1, 12, 14 4,01 11 9
Title XIX Inpatient Days/Outpatient Visits 1-16, 16.01, 18, 21, 23, 24 5 11 9
Title XVIII Inpatient Days (HMO) 2 4 11 9
Title XIX HMO days for IRF
subproviders 2.01 and subscripts 5 11 9
Total Medicaid Observation Bed Days 26 5 11 9
Title XIX Observation Beds Admitted 26 5,01 11 9
Title XIX Observations Beds not Admitted 26 5,02 11 9
Total Inpatient Days/Outpatient Visits 1, 3-16, 16.01, 17, 18, 21, 23, 24 6 11 9
Observation Bed Days 26 6 11 9
Observation Bed Days (Off Site Subprovider) 26,01 6 11 9
Observation Bed Days (Admitted) 26 6,01 11 9
Observation Bed Days (Not Admitted) 26 6,02 11 9
Ambulance Trips 27 4 11 9
Ambulance Trips (if required) 27.01-27.03 4 11 9
Employee Discount Days 28 6 11 9
Employee Discount Days for IRF
subproviders 28.01 and subscripts 6 11 9
For Internal HCRIS:
Lines 26, 26.01, and 28, Column 6 and Lines 27 and 27.01, CoL 4
are identified in the HCRIS Master as follows:
T10: Column 4.01 , Lines 1, 12, and 14 added. Line HCRIS Line/Col Identifier
Line 2.01, Column 5 added.